Letters
1. Cohen A, Assyag P, Boyer-Chatenet L, et al; Réseau Insuffisance Cardiaque (RESICARD) PREVENTION Investigators. An education program for risk factor management after an acute coronary syndrome: a randomized clinical trial. JAMA Intern Med. 2014;174(1):40-48.
Every patient should be cared for in an environment that can provide the core elements described by Walke and Tinetti,1 including multidisciplinary team communication across settings of care; shared decision-making addressing goals of care; social factors identified and social supports provided; and assessment of cognition, function, and symptom burden as measures of health status. Specific care processes should be performed for any at-risk acutely ill elderly patient (eg, delirium risk screening triggering delirium prevention order sets) that make for more geriatric-friendly environments regardless of the admitting physician. Perhaps a larger question should be raised, which is whether the best-designed hospital system is the appropriate location of care for many elderly patients. For decades we have been tinkering at the edges and achieving laudable improvements in process measures, cost, efficiency, and functional outcomes. However, a broader vision is needed that re-envisions the continuum of illness and asks not how we can do better within our silo of care but how the system itself can be fundamentally redesigned to meet the real needs of the patient in the locale which benefits them most. Ultimately, acute geriatric care must be liberated from ACE models to provide geriatric-centric care throughout the hospital and beyond.
2. Bernal DD, Stafford L, Bereznicki LR, Castelino RL, Davidson PM, Peterson GM. Home medicines reviews following acute coronary syndrome: study protocol for a randomized controlled trial. Trials. 2012;13:30.
Heidi Wald, MD, MSPH Ethan Cumbler, MD
3. Assyag P, Renaud T, Cohen-Solal A, et al. RESICARD: East Paris network for the management of heart failure: absence of effect on mortality and rehospitalization in patients with severe heart failure admitted following severe decompensation. Arch Cardiovasc Dis. 2009;102(1):29-41.
Author Affiliations: Department of Medicine, University of Colorado School of Medicine, Aurora; Acute Care for the Elderly Service, University of Colorado Hospital, Aurora.
Regarding the Acute Care of the Elderly Model
Corresponding Author: Heidi Wald, MD, MSPH, Department of Medicine, University of Colorado School of Medicine, 13199 E Montview Blvd, Ste 400, Campus Box F480, HCPR, Aurora, CO 80045 ([email protected]).
nate secondary prevention in patients with heart failure and coronary disease (clinicaltrials.gov identifier: NCT01869452). Ariel Cohen, MD, PhD Patrick Assyag, MD Isabelle Boutron, MD, PhD; for the Réseau Insuffisance Cardiaque (RESICARD) PREVENTION Investigators Author Affiliations: Service de Cardiologie, Hôpital Saint-Antoine, Assistance Publique des Hôpitaux de Paris (AP-HP), Université Pierre et Marie Curie, Paris, France (Cohen); Currently in private practice, Paris, France (Assyag); Centre d’Epidémiologie Clinique, Hôpital Hôtel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France (Boutron); Institut National de la Santé et de la Recherche Médicale Unité 738, Paris, France (Boutron); Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (Boutron). Corresponding Author: Ariel Cohen, MD, PhD, Service de Cardiologie, Hôpital Saint-Antoine, AP-HP, Université Pierre-et-Marie-Curie, 184, rue du FaubourgSaint-Antoine, 75571 Paris CEDEX 12, France ([email protected]). Conflict of Interest Disclosures: None reported. Group Information: The RESICARD PREVENTION Investigators comprise all authors of the study by Cohen et al.1
To the Editor Walke and Tinetti1 are spot on in identifying a key challenge for clinicians, researchers, and policy makers interested in improving acute care for older persons. While geriatricians have been adept at developing models of care for older adults, these models serve niche populations in welldesigned silos. While “putting the pieces together” is an appealing image, we need to realize that these models combined are reaching only a fraction of frail elderly patients. We commend Flood2 for adapting the Acute Care of the Elderly (ACE) model by complementing the existing care of hospitalists with expertise from geriatricians and Hung et al3 for liberating the ACE concept from the physical unit. There are many different twists on the ACE model. At the University of Colorado Hospital, we place hospitalists with commitment to geriatric care principles on a service that is a hybrid of ACE and MACE (Mobile Acute Care of the Elderly) models.4 Nonetheless, many elderly patients are not touched by these models. The prevailing model of care provided to acutely ill frail elderly patients is not patient-centered and often causes harm and perpetuates the disability cycle. We must communicate our message more effectively than we have in the past and to disseminate geriatrics care principles more widely than siloed models allow us.
Conflict of Interest Disclosures: None reported. 1. Walke LM, Tinetti ME. ACE, MACE, and GRACE: time to put the pieces together: comment on “effects of an acute care for elders unit on costs and 30-day readmissions.” JAMA Intern Med. 2013;173(11):987-989. 2. Flood KL, Maclennan PA, McGrew D, Green D, Dodd C, Brown CJ. Effects of an acute care for elders unit on costs and 30-day readmissions. JAMA Intern Med. 2013;173(11):981-987. 3. Hung WW, Ross JS, Farber J, Siu AL. Evaluation of the Mobile Acute Care of the Elderly (MACE) service. JAMA Intern Med. 2013;173(11):990-996. 4. Wald HL, Glasheen JJ, Guerrasio J, Youngwerth JM, Cumbler EU. Evaluation of a hospitalist-run acute care for the elderly service. J Hosp Med. 2011;6(6): 313-321. 5. Cryer L, Shannon SB, Van Amsterdam M, Leff B. Costs for “hospital at home” patients were 19 percent lower, with equal or better outcomes compared to similar inpatients. Health Aff (Millwood). 2012;31(6): 1237-1243.
CORRECTION Error in Byline: In the Original Investigation titled “Observational Modeling of Strict vs Conventional Blood Pressure Control in Patients With Chronic Kidney Disease” published online August 4, 2014, in JAMA Internal Medicine (2014;174[9]:14421449. doi:10.1001/jamainternmed.2014.3279), there was an error in the byline. The correct spelling is “Kamyar Kalantar-Zadeh, MD, MPH, PhD.” The error also occurred in the Author Affiliations and the Author Contributions. This article was corrected online.
jamainternalmedicine.com
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Purdue University User on 05/20/2015
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1. Cohen A, Assyag P, Boyer-Chatenet L, et al; Réseau Insuffisance Cardiaque (RESICARD) PREVENTION Investigators. An education program for risk factor management after an acute coronary syndrome: a randomized clinical trial. JAMA Intern Med. 2014;174(1):40-48.
Every patient should be cared for in an environment that can provide the core elements described by Walke and Tinetti,1 including multidisciplinary team communication across settings of care; shared decision-making addressing goals of care; social factors identified and social supports provided; and assessment of cognition, function, and symptom burden as measures of health status. Specific care processes should be performed for any at-risk acutely ill elderly patient (eg, delirium risk screening triggering delirium prevention order sets) that make for more geriatric-friendly environments regardless of the admitting physician. Perhaps a larger question should be raised, which is whether the best-designed hospital system is the appropriate location of care for many elderly patients. For decades we have been tinkering at the edges and achieving laudable improvements in process measures, cost, efficiency, and functional outcomes. However, a broader vision is needed that re-envisions the continuum of illness and asks not how we can do better within our silo of care but how the system itself can be fundamentally redesigned to meet the real needs of the patient in the locale which benefits them most. Ultimately, acute geriatric care must be liberated from ACE models to provide geriatric-centric care throughout the hospital and beyond.
2. Bernal DD, Stafford L, Bereznicki LR, Castelino RL, Davidson PM, Peterson GM. Home medicines reviews following acute coronary syndrome: study protocol for a randomized controlled trial. Trials. 2012;13:30.
Heidi Wald, MD, MSPH Ethan Cumbler, MD
3. Assyag P, Renaud T, Cohen-Solal A, et al. RESICARD: East Paris network for the management of heart failure: absence of effect on mortality and rehospitalization in patients with severe heart failure admitted following severe decompensation. Arch Cardiovasc Dis. 2009;102(1):29-41.
Author Affiliations: Department of Medicine, University of Colorado School of Medicine, Aurora; Acute Care for the Elderly Service, University of Colorado Hospital, Aurora.
Regarding the Acute Care of the Elderly Model
Corresponding Author: Heidi Wald, MD, MSPH, Department of Medicine, University of Colorado School of Medicine, 13199 E Montview Blvd, Ste 400, Campus Box F480, HCPR, Aurora, CO 80045 ([email protected]).
nate secondary prevention in patients with heart failure and coronary disease (clinicaltrials.gov identifier: NCT01869452). Ariel Cohen, MD, PhD Patrick Assyag, MD Isabelle Boutron, MD, PhD; for the Réseau Insuffisance Cardiaque (RESICARD) PREVENTION Investigators Author Affiliations: Service de Cardiologie, Hôpital Saint-Antoine, Assistance Publique des Hôpitaux de Paris (AP-HP), Université Pierre et Marie Curie, Paris, France (Cohen); Currently in private practice, Paris, France (Assyag); Centre d’Epidémiologie Clinique, Hôpital Hôtel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France (Boutron); Institut National de la Santé et de la Recherche Médicale Unité 738, Paris, France (Boutron); Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France (Boutron). Corresponding Author: Ariel Cohen, MD, PhD, Service de Cardiologie, Hôpital Saint-Antoine, AP-HP, Université Pierre-et-Marie-Curie, 184, rue du FaubourgSaint-Antoine, 75571 Paris CEDEX 12, France ([email protected]). Conflict of Interest Disclosures: None reported. Group Information: The RESICARD PREVENTION Investigators comprise all authors of the study by Cohen et al.1
To the Editor Walke and Tinetti1 are spot on in identifying a key challenge for clinicians, researchers, and policy makers interested in improving acute care for older persons. While geriatricians have been adept at developing models of care for older adults, these models serve niche populations in welldesigned silos. While “putting the pieces together” is an appealing image, we need to realize that these models combined are reaching only a fraction of frail elderly patients. We commend Flood2 for adapting the Acute Care of the Elderly (ACE) model by complementing the existing care of hospitalists with expertise from geriatricians and Hung et al3 for liberating the ACE concept from the physical unit. There are many different twists on the ACE model. At the University of Colorado Hospital, we place hospitalists with commitment to geriatric care principles on a service that is a hybrid of ACE and MACE (Mobile Acute Care of the Elderly) models.4 Nonetheless, many elderly patients are not touched by these models. The prevailing model of care provided to acutely ill frail elderly patients is not patient-centered and often causes harm and perpetuates the disability cycle. We must communicate our message more effectively than we have in the past and to disseminate geriatrics care principles more widely than siloed models allow us.
Conflict of Interest Disclosures: None reported. 1. Walke LM, Tinetti ME. ACE, MACE, and GRACE: time to put the pieces together: comment on “effects of an acute care for elders unit on costs and 30-day readmissions.” JAMA Intern Med. 2013;173(11):987-989. 2. Flood KL, Maclennan PA, McGrew D, Green D, Dodd C, Brown CJ. Effects of an acute care for elders unit on costs and 30-day readmissions. JAMA Intern Med. 2013;173(11):981-987. 3. Hung WW, Ross JS, Farber J, Siu AL. Evaluation of the Mobile Acute Care of the Elderly (MACE) service. JAMA Intern Med. 2013;173(11):990-996. 4. Wald HL, Glasheen JJ, Guerrasio J, Youngwerth JM, Cumbler EU. Evaluation of a hospitalist-run acute care for the elderly service. J Hosp Med. 2011;6(6): 313-321. 5. Cryer L, Shannon SB, Van Amsterdam M, Leff B. Costs for “hospital at home” patients were 19 percent lower, with equal or better outcomes compared to similar inpatients. Health Aff (Millwood). 2012;31(6): 1237-1243.
CORRECTION Error in Byline: In the Original Investigation titled “Observational Modeling of Strict vs Conventional Blood Pressure Control in Patients With Chronic Kidney Disease” published online August 4, 2014, in JAMA Internal Medicine (2014;174[9]:14421449. doi:10.1001/jamainternmed.2014.3279), there was an error in the byline. The correct spelling is “Kamyar Kalantar-Zadeh, MD, MPH, PhD.” The error also occurred in the Author Affiliations and the Author Contributions. This article was corrected online.
jamainternalmedicine.com
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Purdue University User on 05/20/2015
1709
